1. U PPER GI. BLEEDING Prepared by: Juhin B. Duaneh PPP U29 Unit Endoskopi.

2. I NTRODUCTION Acute gastrointestinal bleeding is a potentially life-threatening abdominal emergency that remain a common hospitalization. Upper gastrointestinal bleeding is defined as bleeding derived from source proximal to the ligament of Treitz. Can be categorized as either variceal or non variceal. Variceal is a complication of end stage liver desease. While non variceal bleeding associated with peptic ulcer desease or other causes of UGIB. UGIB is 4 times as common as bleeding from lower GIT, with higher incidence in male.

5. CAUSES Esophageal causes: Esophageal varices. Esophagitis. Esophageal cancer. Esophageal ulcers Mallory-weiss tear. o Gastric Causes. Gastric ulcer Gastric cancer. Gastritis. Gastric varices Dieulafoy’s lesions.

6. CAUSES Duodenal Causes. Duodenal ulcer. Vascular malformation including aorto- mesentric. Hematobilia, or bleeding from biliary tree. Hemosuccus pancreaticus. Severe superior mesenteric artery syndrome.

8. S IGN AND SYMPTOMS Hematemasis Malena Hematochezia Dyspepsia Hurtburn Epigastric pain. Dysphagia Weight loss

9. C OMMON PRESENTATION Hematemasis : vomiting of blood, could be : digested blood in the stomach (coffee-ground emesis that indicate slower rate of bleeding) or fresh blood (groosh blood and cloths, indicates rapid bleeding). Malena: stool consisting of paertially digested bood (black tarry, semi solid and has a distinctive odor, when its present it indicates that blood has been presen in the GI tract for at least 14 h. Hematochezia usually representa a lower GI source of bleeding, althhough an upper GI lesion may bleesd so briskly that blood not remain in the bowel long enough for malena develop.

10. APPROACH History : Abdominal pain. Heamatamesis Hematochezia Malena Features of blood loss: shock, syncope, anemia. Features of underlying cause: dyspepsia, jaundice, weight loss. Hisory of epitaxis or hemoptysis to rule out the GI source of bleeding.

11. Past medical history: preavious episodes of upper gastrointestinal bleeding, coronary artery disease, chronic renal or liver disease, or chronic ppulmonary disease. Past sugical: previous abdominal surgery.

12. A PPROACH CONT  Examination : General examinattion and systemic examinations. Vital sign. Pulse Bp Spo2 o Sign of shock: Cold extremeties, tachycardia, hypotension, chest pain, confusion, delirium, oliguria.

13. Skin chnges: Cirrhosis – Palmer erythema, spider nevi. Bleeding disorders – Purpura / Echymosis. Coagulation disorders – Heamarthrosis, Muscle hematoma. o Sign of dehydration (dry mocusa, sunken eys, skin turgor reduced). o Sign of a tumor may be present (nodular liver, abdominal mass, lymphadenopathy.

14. L AB DIAGNOSIS Full blood count is necessary to assass the level of blood loss. FBC shoul be checked frequently during the first day. LFT – to detect underlying liver disease. RFT – to detect underlying reanal disease The patient’s prothrombin time (PT), activated partial thromboplastin time, and International Normalized Ratio (INR)should be checked to do document the presence of a coagulopathy. Prolongation of the PT based on an INR of more than 1.5 my indicate moderate liver impairment. Gastrin level

15. ENDOSCOPY Initial diagnostic examination for all patients presumed to have UGIB Endoscopy should be performed immediately after endotracheal intubation (if indicated), hemodynamic stabilization, and adequate monitoring in an intensive care unit (ICU) setting have been achieved.

18. IMAGING Chest X-Ray- should be odered to exclude aspiration pneumonia, effusion, and esophageal perforation. Abdominal X-Ray erect and supine films should be odered to exclude perforated viscous and ileus.

19. N ASOGASTRIC LAVAGE A nasogastric tube is an important diagnostic tool. This procedura may confirm recent bleeding (coffe ground appearance), possible active bleeding (red blood iun the aspirate that does not clear).

20. B ENEFITS OF LAVAGE : Better visualization during endoscopy. Give crude estimitation of rapidity of bleeding. Prevent the development of porto systemic encephalopathy in cirrhosis. Increase ph of stomach, and hence, decrease clot desolation due to gastri acid dilution Tube palecemen can reduce the patient’s need to vomit.  During gastric lavage use saline and not use large volume of to avoid water intoxication.  Gastric lavage should be done in allert and coperative patient to avoid bronco-pulmonary aspiration.

21. MANGEMENT Priorities are: Stabilize patient: protect airway, restore circulation. Identify the source of bleeding. Definitive treatment of the cause. o Ressuscitation and initial management. Protect airway: position the patient on side. IV access: use 1-2 large bore cannula Take blood for HB, PCV,PT and cross match

22. Restore the circulation: if patient haemodynamically stable give N.S infusion. If not give colloid 500ml/1hr and then crystalloid and continue until blood is avaiable.

23. Tranfuse blood for: Obvious massive blood loss Hematocrit <25% with active bleeding. Symtoms due to low hematocrit and hemoglobin. o Platelet transfusion should be offered to patients who are are actively bleeding and have platelet count of <50000. o Fresh frozen plasma should be used for patients who have either a fibrinogen level of less than 1g/litre or (INR) greater than 1.5times normal.

24. Monitor urine output. Watch for signs of fluid overload. Commence IV PPI, omeprazole 80mg iv followed by 8mg/hr for 72 hours. Keep the pt nill by mouth for endoscopy.

25. T REATMENT ( ENDOSCOPY ) TREATMENT OF VARICEAL BLEEDING 1. Esophageal Varices  Band ligation.  Transjugular intrahepatic portosystemic shunts (TIPS) should be considered if bleeding from osophageal varices is is not controlled by band ligation. 2. Gastric varices:  Endoscopic injection of N-butyl-2-cyanoacrylate should be used.  Transjugular intrahepatic portosystemic shunts (TIPS) should be considered if bleeding from osophageal varices is is not controlled by band ligation.  Ballon tamponade should be considered as temporary salvage treatment for uncontrolled varicel haemorrhage.

30. TREATMENT TREATMENT OF NON-VARICEAL BLEEDING For the endoscopic treatment of non-variceal UGIB, one of the following should be used: 1. A mechanical method (clip) with or without adrenaline. 2. Thermal coagulation with adrenaline. 3. Fibrib or thrombin with adrenaline.

32. T REATMENT FOR SURGERY 1. Persistent hypotension. 2. Failure of medical treatment or endoscopic homeostasis 3. Coexisting condition (perforation, obtruction, maglinancy) 4. Transfusion requirement (4 unit in 24 hr) 5. Recurrent hopsitalizations